BJ Form No.

20
REPUBLIC OF THE PHILIPPINES
CITY OF MANILA
BARANGAY _________, ZONE _____, DISTRICT_____

OFFICE OF THE LUPON TAGAPAMAYAPA

_______________________
_______________________

Barangay Case No. ________

For: ____________________

Complaint/s,

-against______________________
______________________
Respondent/s.

X-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- x

CERTIFICATION TO FILE ACTION

This is to certify that:
1. There has been a personal confrontation between the parties before the Punong
Barangay/Pangkat ng Tagapagkasundo;
2. A settlement was reached;
3. The settlement has been repudiated in a statement sworn to before the Punong
Barangay by ________________ on ground on _______________;
Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.
This____ day of _____________________, 201___.
__________________________
Lupon Secretary
ATTESTED BY:
__________________________
Lupon Chairman